You’re sitting in your cozy reading room moving efﬁciently through loads of studies. Whimsically, you think, “Maybe I’ll get out of here before rush hour starts in earnest.” Suddenly, your daydream ruptures as the door ﬂies open and there stands your friendly, neighborhood internist colleague holding what looks like a year’s worth of radiographs, CTs, and MRIs from the U.S. Olympic Team. Actually, these ﬁlms belong to a single patient who has been transferred to your illustrious institution from Elsewhere General for deﬁnitive care, sometimes referred to as “pre-mortem care.”
is the Editor-in-Chief of this journal and a Professor of
Radiology, Diagnostic Imaging Department, University of Maryland
Medical Center, Baltimore, MD.
You're sitting in your cozy reading room moving efficiently
through loads of studies. Whimsically, you think, "Maybe I'll get
out of here before rush hour starts in earnest." Suddenly, your
daydream ruptures as the door flies open and there stands your
friendly, neighborhood internist colleague holding what looks like
a year's worth of radiographs, CTs, and MRIs from the U.S. Olympic
Team. Actually, these films belong to a single patient who has been
transferred to your illustrious institution from Elsewhere General
for definitive care, sometimes referred to as "pre-mortem
Clinician: "Would you mind taking a quick a look at these
outside studies"? (The studies are from the last 4 years on a Mr.
Zepicholawiscki, a 90-year-old gentleman with some kind of really
You think: "Yes, I certainly would mind looking at these. It
will take me until next Thursday just to get them in order and we
don't have view boxes anymore." Moreover, you ponder: "Why in the
Lord's name would you want me just to have a quick look? How about
I just give them my slow, but still careless, perusal?" An official
"dictated" interpretation will take another week.
You say: "Of course, I'd be happy to."
Clinician: "Just let me know if you agree with all the
interpretations of the other 37 radiologists. Oh, by the way, I
think some of the films are stuck together because of the flood at
Elsewhere General. We can repeat anything you are concerned
You think: "I would like to do a barium enema on you, my
clinical friend, with enough air to make your eyes pop out."
You say: "Well, I'll do my best."
Clinician: "Also, he's scheduled for the OR in an hour, and the
surgeons would really like your opinion. They respect you so
You think: "I'm going to clean out that OR with an Uzi."
You say: "Sure, no problem, glad to help."
Perhaps I'm slightly exaggerating the difficulties we
radiologists may experience when asked to review outside imaging
studies. There are a lot of thorny issues wrapped up in this
process. On the positive side, at least one of your colleagues
respects your opinion over that of the largely unknown outside
radiologist, even though there is no real data to suggest that you
would be worthy to clean off that radiologist's monitor. For all
you know, that other radiologist may be the world's expert on Mr.
Zepicholawiscki's strange malady.
If you question the accuracy of the interpretation of these
studies involving numerous outside radiologists (many of whom
attended your daughter's wedding), you may be creating a
medicolegal issue for one or more of you if Mr. Z takes a sudden
turn for the worse. Well, perhaps you can give just a "roadside" or
"hall-side" or "bathroom-side" opinion. Unfortunately, your lawyer
friend (is this an oxymoron?) told you that the radiologist reading
films held up to an overhead light
is legally termed the "defendant."
OK, you can ask the file clerk (the person who used to lose your
films) to digitize the entire set of studies to the PACS network
for an official, written-in-stone, for-the-world-to-see
interpretation. This approach requires you to get the clinician or
his appointed minion to request a second interpretation of the
studies in your ordering system. (This small task often proves to
be more of a stumbling block than getting all of the films
digitized.). Interestingly, one request suffices for all 87 studies
to be reinterpreted, and the potential reimbursement will almost
buy a gallon of gas. Obviously, the third-party payers don't have
much respect for your opinion. They go with the first call;
anything after that is gravy.
To add salt to your wound, you notice that Mr. Z. has had many
studies performed in the private offices of your major rural
competitors, since your big city hospital is too far to drive to
and actually charges for parking. If Mr. Z survives this visit to
your hospital, he will wind up getting all his follow-up work done
at that group with the gravity-free massage chairs and a Starbucks
in their waiting room.
OK, I got it. If I just take a real quick look and tell them
what I think (off the record
), I can give the films to the file clerk, then no one will ever
see them again. Oh, how I long for the good old days when you could
really depend on some things. Gee, I hope they're not just
For the serious-minded among you, check out the American College
of Radiology (ACR) guidelines below.
Occasionally, a diagnostic imager may be asked to provide an
interpretation that does not result in a "formal" report but is
used to make treatment decisions. Such communications may take the
form of a "curbside consult," a "wet reading," or "informal
opinion" that may occur during clinical conferences,
interpretations while involved in other activities, or review of an
outside study. These circumstances may preclude immediate
documentation and may occur in suboptimal viewing conditions
without comparison studies or adequate patient history. Informal
communications carry inherent risk, and frequently the clinician's
documentation of the informal consultation may be the only written
record of the communication. Diagnostic imagers who provide
consultations of this nature in the spirit of improving patient
care are encouraged to document those interpretations. A system for
reporting outside studies is encouraged.